Provider Demographics
NPI:1154432706
Name:EAST TEXAS MEDICAL SPECIALTIES
Entity type:Organization
Organization Name:EAST TEXAS MEDICAL SPECIALTIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-564-2710
Mailing Address - Street 1:3226 N UNIVERSITY DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2698
Mailing Address - Country:US
Mailing Address - Phone:936-564-2710
Mailing Address - Fax:936-564-2791
Practice Address - Street 1:3226 N UNIVERSITY DR STE 200
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2698
Practice Address - Country:US
Practice Address - Phone:936-564-2710
Practice Address - Fax:936-564-2791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9503207RN0300X
TXK4263208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142409501Medicaid
TX00176RMedicare ID - Type Unspecified